2017-02-15T13:59:56-08:00 2016-03-31 990 2015-04-01 930386823 LEGACY EMANUEL HOSPITAL & HEALTH CENTER LEGA 5034155600 2801 N GANTENBEIN AVENUE PORTLAND OR 97227 LINDA S HOFF CFO & Treasurer 2017-02-15 2015 2021-01-29 14:40:06Z GEORGE J BROWN MD C/O 1919 NW LOVEJOY STREET PORTLAND OR 97209 788802676 false false X WWW.LEGACYHEALTH.ORG X 1912 OR Legacy Emanuel Hospital & Health Center(LEHHC), established in 1912, provides acute and tertiary care in northeast Portland, with 554 licensed beds. LEHHC operates Randall Children's hospital, Level I Trauma Center, the Oregon Burn Center and high-risk obstetric services including a Level III NICU. LEHHC provides a comprehensive range of inpatient, clinical and diagnostic services in numerous medical specialties and subspecialties. LEHHC is part of Legacy Health (Legacy).Our mission:Our legacy is good health for our people, our patients, our communities, and our world. We will work as a team to demonstrate our values:Respect - Treat all people with respect and compassion Service - Put the needs of our patients and their families first Quality - Deliver outstanding clinical services within healing environments Excellence - Set high standards and achieve them Responsibility - Be good stewards of our resources, ensuring access to care for all Innovation - Be progressive in our thinking an 16 2 0 611 27815931 -1276259 10996782 10764379 719051843 772889261 10776418 4267811 100223 0 740925266 787921451 110556 133616 0 403340218 460377779 0 0 306918247 342492302 710369021 803003697 30556245 -15082246 543726735 497130419 377258405 364252497 166468330 132877922 Legacy Emanuel Hospital & Health Center(LEHHC), established in 1912, provides acute and tertiary care in northeast Portland, with 554 licensed beds. LEHHC operates Randall Children's hospital, Level I Trauma Center, the Oregon Burn Center and high-risk obstetric services including a Level III NICU. LEHHC provides a comprehensive range of inpatient, clinical and diagnostic services in numerous medical specialties and subspecialties. LEHHC is part of Legacy Health (Legacy).Our mission:Our legacy is good health for our people, our patients, our communities, and our world. We will work as a team to demonstrate our values:Respect - Treat all people with respect and compassion Service - Put the needs of our patients and their families first Quality - Deliver outstanding clinical services within healing environments Excellence - Set high standards and achieve them Responsibility - Be good stewards of our resources, ensuring access to care for all Innovation - Be progressive in our thinking an false false 521433707 133616 655166245 LEHHC provides a comprehensive range of inpatient, clinical and diagnostic services in numerous medical specialties and subspecialties. LEHHC provides training for interns and residents through its nationally accredited graduate medical education program. LEHHC operates primary care teaching clinics at LEHHC and in St. Helens, located approximately 30 miles from the main LEHHC campus. In addition to its core hospital services, LEHHC provides related health services through the following programs:The Randall Children's Hospital; Legacy Research; Legacy Laboratory Services, LLC(Lab); Legacy Metro LabThe Randall Children's Hospital at Legacy Emanuel is a full-service children's hospital within LEHHC committed to providing care in an environment sensitive to the special needs of children and their families, including premature and critically ill newborns. The Randall Children's Hospital treats children from throughout Oregon, southwest Washington, Alaska and Idaho.Legacy Research is a full-service research facility that supports a wide range of research activity. Legacy Research collaborates with pharmaceutical, biotechnology and medical device companies. Legacy Research is located in northeast Portland (Holladay Park campus).LEHHC is one of four members of an emergency air transport service joint venture, Life Flight Network LLC, which serves Oregon and southwest Washington.In support of its mission, LEHHC voluntarily provides medically necessary patient care services that are discounted or free of charge to persons who have insufficient resources and/or who are uninsured. During fiscal year 2016, LEHHC provided financial assistance on approximately 12,320 patient accounts (of which 31% received discounts totaling 100% of costs) and resulted in LEHHC incurring roughly $14,515,000 in uncompensated costs associated with this program. In addition to charity care, LEHHC provides services under various states' Medicaid programs for financially needy patients, Medicare beneficiaries, and other government programs for which the cost of treating these patients exceeds the government payments received. During fiscal year 2016, LEHHC incurred approximately $102,299,300, $46,793,000 and $1,141,700 in uncompensated costs attributable to Medicaid, Medicare, and other government programs, respectively. LEHHC also provides a variety of other community benefit activities such as medical education, donations to other charitable entities, research, and other health improvement services which totaled roughly $15,241,700 during fiscal year 2016.LEHHC is part of Legacy, which collectively provided over $29 million, $167 million, $102 million, and $2 million in uncompensated care attributable to its financial assistance, Medicaid, Medicare, and other government programs, respectively, in fiscal year 2016. 112704432 74564297 LEHHC is the sole member of Legacy Clinics, LLC, an Oregon limited liability company, which operates over forty primary care and specialty clinic sites throughout the Portland Metropolitan area. In addition, Legacy Clinics operates the hospitalist and intensivist programs at the four Legacy Health Oregon hospitals. 33001923 43158719 LEHHC is the sole member of Legacy Laboratory Service, LLC (Lab), an Oregon limited liability company which is located at the Holladay Park campus and operates and manages multiple locations throughout the greater Portland area, the Willamette Valley and the central Oregon coast. The Lab also provides outpatient laboratory services to over 2,500 physicians located in Oregon and southwest Washington. Test and service offerings support the medical community and programs offered by the System through specialized services, such as its cytogenetics, medical genetics and cellular and molecular diagnostics laboratories, as well as clinical laboratory support. Prior to April 1, 2009, Legacy Laboratory Services operated as a division of LEHHC.Legacy MetroLab (a dba of LEHHC) is a nationally certified toxicology laboratory supporting business and industry clients throughout the United States. 667140062 true true false true false false false false false true true true false false true false false true false false false false false false false false true true true true true false false false false false false true false false false false false false false false true true true false false false true 0 0 false 0 false true true false false false false false false 0 false false false false false false false false false false X 16 2 false true false false true true true true true false false true true true true true true true true true true OR X X LINDA S HOFF 5034155600 1919 NW LOVEJOY STREET PORTLAND OR 97209 BISHOP DAVID BRAUER-RIEKE BOARD DIRECTOR 3.00 0.00 X 0 0 0 JEFFREY BARBER BOARD DIRECTOR 3.00 0.00 X 0 13132 0 JONATHAN HILL MD BOARD DIRECTOR 40.00 3.00 X 380204 11500 22059 JAMES WALKER BOARD DIRECTOR 3.00 0.00 X 0 14917 0 ROBERT L CORNIE BOARD DIRECTOR 4.00 0.00 X 0 18731 0 JEFFREY D FULLMAN MD Chairman 3.00 0.00 X X 0 40283 0 JEFFREY S GORDON Chairman 5.00 0.00 X X 0 31750 0 RONALD S KING VICE CHAIR 4.00 0.00 X X 0 33000 0 PATRICK REITEN BOARD DIRECTOR 3.00 0.00 X 0 13500 0 CORLISS A MCKEEVER BOARD DIRECTOR 3.00 0.00 X 0 11000 0 RT REV MICHAEL J HANLEY BOARD DIRECTOR 3.00 0.00 X 0 0 0 STEPHEN NEWBERRY MD BOARD DIRECTOR 3.00 1.00 X 0 12000 0 JOHN W WINTER JR BOARD DIRECTOR 4.00 0.00 X 0 24500 0 SHERYL MANNING BOARD DIRECTOR 4.00 0.00 X 0 19750 0 ROBERT E DEWITT Secretary 0.00 40.00 X X 0 443595 40788 LESLIE ROOT MD BOARD DIRECTOR 1.00 4.00 X 0 16837 0 GEORGE J BROWN MD President & CEO 0.00 40.00 X X 0 1810933 467935 DAVID RAMUS BOARD DIRECTOR 3.00 0.00 X 0 9250 0 CHARLES WILHOITE BOARD DIRECTOR 3.00 0.00 X 0 0 0 DIANE PINNEY BOARD DIRECTOR 4.00 0.00 X 0 11000 0 LINDA S HOFF CFO & TREASURER 0.00 40.00 X X 0 659680 179147 MOLLY F BURCHELL MD VP 40.00 0.00 X 421470 0 59938 CAROL A BRADLEY SR VP 0.00 40.00 X 0 446480 67426 TRENT S GREEN SR VP 0.00 40.00 X 0 505430 154095 LEWIS L LOW MD SR VP 0.00 40.00 X 0 607597 85666 MELINDA J MULLER MD VP 40.00 0.00 X 401546 0 68375 DUNCAN R NEILSON MD VP 40.00 0.00 X 486411 0 55857 DONALD A TOUSSAINT VP 40.00 0.00 X 273628 0 47379 SONJA O STEVES SR VP 0.00 40.00 X 0 408685 89604 LORI J MORGAN MD PRESIDENT/CAO 40.00 0.00 X 534839 0 76930 P ASHLEY WACKYM MD VP LEGACY RESEARCH 40.00 0.00 X 473026 0 62263 EVERETT W NEWCOMB III MD SR VP 0.00 40.00 X 0 838091 216944 MAUREEN A BRADLEY SR VP 0.00 40.00 X 0 341606 50018 JOHN J KENAGY SR VP 0.00 40.00 X 0 474101 140331 MADLYN A MURREY PRESIDENT/CAO 40.00 0.00 X 292456 0 28364 BRIAN P YOUNG MD VP 40.00 0.00 X 424258 0 53836 BRONWYN J HOUSTON PRESIDENT/CAO 40.00 0.00 X 178746 0 42607 KEYVAN ABTIN MD NEUROSURGEON 40.00 0.00 X 776025 0 44854 RAMNIK S JHOOTY MD CARDIOLOGIST 40.00 0.00 X 699335 0 39120 MONICA C WEHBY MD PED NEUROSURGEON 40.00 0.00 X 748679 0 39094 JOHN P IGUIDBASHIAN MD CARDIO SURGEON 40.00 0.00 X 959335 0 65688 SANDRA M WANEK MD ECMO SURGEON 40.00 0.00 X 953157 0 22124 8003115 6817348 2220442 847 false true false BAUGH SKANSKA INC 222 SW COLUMBIA ST 300 PORTLAND OR 97201 CONSTRUCTION 19651315 TRAUMA SPECIALISTS LLP 1620 SW TAYLOR PORTLAND OR 97205 MEDICAL SERVICES 10166225 BLOODWORKS NORTHWEST 921 TERRY AVE SEATTLE WA 98104 MEDICAL SERVICES 3563906 ASSOCIATED REGIONAL & UNIVERISTY PATHOLOGISTS 500 CHIPETA WAY SALT LAKE CITY UT 84108 MEDICAL SERVICES 2952598 NBBJ LP PO BOX 742088 LOS ANGELES CA 90074 ARCHITECTURE 4439836 55 4070244 6446841 247294 10764379 CONVENIENCE OF MEMBERS 3614289 3614289 LAB, PHARMACY, ETC 87265951 29630645 57635306 PATIENT PROGRAM REV 1438963155 1438963155 PHYSICIANS 48811224 48811224 REVENUE CLINICS 143552688 143552688 -949318046 -919498671 -29819375 772889261 4003686 4003686 0 0 0 1145350 881225 264125 264125 264125 0 0 0 0 787921451 741459041 27815931 7882100 17586 17586 116030 116030 0 0 4384193 3987300 396893 0 367944853 340154452 27790401 20462232 18918567 1543665 41242414 37355081 3887333 26344087 24420944 1923143 0 268335 223270 45065 0 0 0 0 23653848 23653848 0 118348269 114074538 4273731 0 0 7622622 6626617 996005 987638 879705 107933 0 0 7400857 6022531 1378326 0 32207387 26721591 5485796 5938941 5192793 746148 ADMINISTRATIVE SERVICES FEES 101876586 15461738 86414848 PROVIDER TAX 34909186 34909186 BAD DEBTS 8299078 8299078 CONSULTING 979555 105207 874348 0 803003697 667140062 135863635 0 -1881875 285913 0 0 109625313 120805210 0 0 1106320 882893 7834538 8585063 471865 162703 605971956 289638734 315416952 316333222 0 96369846 32973573 0 0 14783776 17101842 543726735 497130419 51402146 63874457 325856259 300378040 377258405 364252497 X 165355889 131567616 1112441 1310306 166468330 132877922 543726735 497130419 X -15082246 -18508162 X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false X 14143 349884 14143 349884 674277113 956235965 674291256 956585849 1000000 1000000 250000 250000 false 2000000 2000000 2000000 2000000 8000000 12000000 290854 355538 317778 364027 1328197 500000 500000 500000 500000 2000000 3000000 8029966 7174135 -97570 2843964 12262567 7469350 1945101 142846 1527331 8029966 10275395 2260926 302623 5369594 7469350 13328808 2885506 169983 6108902 10275395 7279381 11627099 22758 5600430 13328808 0.82000 0.18000 false true true 2822665 2822665 376291866 140648730 235643136 6246394 2101841 4144553 212048658 146888163 65160495 8562373 8562373 316333222 32973573 I/C AFFILIATE DEBT 235703789 NONCURRENT ENVIRONMENTAL OBLIGATION 1457826 NONCURRENT PENSION LIABILITY 62147031 NONCURRENT WORKERS' COMP LIABILITY 1069392 Rounding 2 300378040 769379000 769379000 18542451 18542451 787921451 784932000 784932000 18071697 18071697 803003697 Part V, Line 4: Intended uses of the endowment fund. Endowment funds disclosed in Part V are used to improve the healthcare of the community as designated by the donors. Emanuel Medical Center Foundation (EMCF) and Randall Children's Hospital Foundation (RCHF) maintain all charitable gifts including endowment funds for the benefit of LEHHC and it's programs. Income from permanently restricted net assets is accounted for in accordance with the donors' instructions.Legacy follows the guidance in the Uniform Prudent Management of Institutional Funds Act (UPMIFA) in determining the net asset classification of all donor-restricted endowment funds. In accordance with UPMIFA and board policy, assets classified as permanent endowments in accordance with donor intent are only utilized for current period expenditures to the extent that earnings on the endowment exceed the original fair value of the donation. To the extent earnings on endowment funds exceed identified expenditures on which to apply those earnings, the earnings are classified as temporarily restricted net assets. Legacy has adopted investment and spending policies for endowment assets to provide a predictable stream of funding to programs supported by its endowment and to maintain the value of the endowment assets. Asset allocation is reviewed quarterly with respect to: i) Legacy's tolerance for risk based on its financial condition and need for cash from investments to support operations; ii) expected asset class return, risk and correlation characteristics; iii) changes in accounting guidance or tax law and iv) changes in bond covenants or other restrictions.Legacy's spending practices are intended to comply with donor's wishes and meet all applicable laws and regulations. Spending must be for a purpose that is consistent with the documented intent of the donor, and may not exceed the amounts annually determined by Legacy. Factors that are considered in addressing the annual spending allocation are: i) market value of the fund relative to the principal of the gift and ii) the level of spending in prior years.From time to time, the fair value of assets associated with individual donor-restricted endowment funds may fall below the level that the donor or UPMIFA requires Legacy to retain as a fund of perpetual duration. Deficiencies of this nature are reported as a reduction to unrestricted net assets and are excluded from the performance indicator. Part XI, Line 4b: Other revenue amounts included on 990 but not included in F/S REVENUE FROM RESEARCH $11218911 OTHER RECLASS OF REV/EXP FOR TAX PURPOSE $6737017 AUXILIARY INCOME $22467 MEDICAL STAFF INCOME $484300 IN KIND DONATION $0 CAPITAL DONATION IN TOWER PROJECT $0 EMANUEL FOUNDATION DONATION $79756 CHILDREN'S FOUNDATION DONATION $0 Part XII, Line 4b: Other revenue amounts included on 990 but not included in F/S EXPENSE FROM RESEARCH $11021047 OTHER RECLASS OF REV/EXP FOR TAX PURPOSE $6708092 AUXILIARY EXPENSE $-21437 MEDICAL STAFF EXPENSE $473126 ELIMINATE EQUIPMENT DONATIONS $-109131 ROUNDING $0 true true X true X true X true true true false true true 14514936 14514936 0.01810 276849986 174550686 102299300 0.12740 8027611 6885926 1141685 0.00140 299392533 181436612 117955921 0.14690 1076159 412404 663755 0.00080 10074597 4183269 5891328 0.00730 7870337 7870337 0.00980 816243 816243 0.00100 19837336 4595673 15241663 0.01890 319229869 186032285 133197584 0.16580 false 8299078 5062438 57334967 66936378 -9601411 X true true 1 1 LEGACY EMANUEL HOSP & HEALTH 2801 N GANTENBEIN AVENUE PORTLAND OR 97227 www.legacyhealth.org 14-0056 X X X X X X X LEGACY EMANUEL HOSP & HEALTH 1 false false true X X X X X X X X X 14 true true true true X www.legacyhealth.org true 14 true www.legacyhealth.org false false true X 200.0000 400.0000 X X X X X true true X X X true X www.legacyhealth.org X www.legacyhealth.org X www.legacyhealth.org X X X X X true X false X X X X true X false false Part V, Line 5 - Account Input from Persons Who Represent the Community In 2014, Legacy Emanuel Medical Center participated with 14 other hospitals, four public health departments and two Coordinated Care Organizations in the four-county regional Healthy Columbia Willamette Collaborative Community Health Needs Assessment(HCWC CHNA) which was used as a base for the Legacy Emanuel Community Health Needs Assessment. The results of Legacy's community needs assessment can be found at www.legacyhealth.org.The HCWC CHNA is regional and developed to improve efficiency and effectiveness and also to help meet the requirements of the ACA and Public Health Accreditation. The regional CHNA obtained information from the community through a variety of venues -online surveys and interviews with public health, tribal, regional, state or local health or other departments as well as medically underserved, low income and minority populations and those with chronic disease needs; a review of community engagement/needs assessment projects; and community listening sessions with uninsured and/or low-income community members from diverse culturally-identified and geographic communities. In the latest round of work, the Collaborative also reviewed population data (health-related behaviors, morbidity, mortality); medical data from local CCOs (most frequent conditions Medicaid-covered individuals sought care for); and hospital data (uninsured patients seen in the emergency department for conditions that could have been managed in primary or ambulatory care settings). Our work included the following community partners: Adelante Mujeres Adult Mental Health and Substance Abuse Advisory Council Allies for a Healthier Oregon Ant Farm Calvary Church Central City Concern Clackamas County Public Health Advisory Committee Clackamas Service Center Coalition of Community Health Clinics Elders in Action Commission El Programa Hispano FamilyCare Community Advisory Council Free Clinic of SW Washington Hacienda CDC Health Share of Oregon Community Advisory Council Highland Church & Highland Access, Reentry and Recovery Program Immigrant and Refugee Community Organization The Intertwine Alliance Latino Network Liberation Street Church Lifeline Connections LifeWorks Northwest Multnomah County Health Equity Initiative Native American Youth Association National Alliance on Mental Illness (Clackamas) OHSU Richmond Clinic Health Literacy Committee Oregon Community Health Worker Association Oregon Health Equity Alliance Outside In Oregon Foundation for Reproductive Health Oregon Public Health Institute Project Access NOW Q Center Urban League of Portland Veterans Affairs Hospital Washington County Mental Health and Addictions Advisory Council Washington County Public Health Advisory Council Part V, Line 6a - List Other Hospital Facilities that Jointly Conducted Needs Assessment In addition to Legacy Emanuel Medical Center, the other 14 hospitals in the metro area that participated in the Healthy Columbia Willamette Collaborative Community Health Needs Assessment were: Adventist Medical Center, Kaiser Permanente Sunnyside Medical Center, Kaiser Permanente Westside Medical Center, Legacy Good Samaritan Medical Center, Legacy Meridian Park Medical Center, Legacy Mount Hood Medical Center, Legacy Salmon Creek Medical Center, Oregon Health & Science University, Peace Health Southwest Medical Center, Providence Milwaukie Medical Center, Providence Portland Medical Center, Providence St. Vincent Medical Center, Providence Willamette Falls Medical Center and Tuality Health Care/Tuality Community Hospital. Part V, Line 11 - Explanation of Needs Not Addressed and Reasons Why LEHHC did not address needs identified in the Community Needs Assessment for the reasons explained in the following, by need. These are included in the Community Needs Assessment and Implementation Strategies Plan.NEED: Public Health: Limited financial and labor resources prevent addressing as need.NEED: Dental: Limited financial and labor resources prevent addressing as need.NEED: Natural Environment: Limited financial and labor resources prevent addressing as need.NEED: STDS and HIV/AIDS: Limited financial and labor resources prevent addressing as need.NEED: Transgender Care: Limited financial and labor resources prevent addressing as need.NEED: Autism: Limited financial and labor resources prevent addressing as need. Part V, Line 22d - Other Billing Determination of Individuals Without Insurance The hospital facility used the Federal Poverty Guidelines to determine the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care. Discounts are available for patients, on a sliding scale, whose household income is less than 400% of the federal poverty level. A full subsidy is available for patients whose income is at or below 200% of the federal poverty level. 2 Legacy Medical Clinics LLC 1919 NW Lovejoy Street Portland OR 97209 Physician Clinics Legacy Laboratory Services 1225 NE 2nd Ave Portland OR 97232 Diagnostic Laboratory Services Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense LEHHC uses many different approaches to inform and educate patients on the availability of financial assistance as is described later in Part VI of Schedule H. Still, many patients do not respond to requests for information or provide appropriate documentation to benefit from financial assistance. As a result, LEHHC must report these amounts as bad debt. A portion of bad debt expense should be considered as charity care, using reasonable methodologies to analyze the information. Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit The estimated amount of bad debt expenses attributable to charity care policy was calculated using the demographic profile of household income and average household size in the zip code areas around the hospital. 61% of Households in the LEHHC service area would qualify for financial assistance with incomes under 400% of the Federal Poverty Guidelines using this methodology. Part III, Line 8 - Explanation Of Shortfall As Community Benefit The entire Medicare shortfall should be considered a community benefit. Medicare shortfalls must be absorbed by the hospital in order to continue treating the elderly in the community served by the hospital. The hospital provides care regardless of this shortfall and thereby relieves the federal government of the burden of paying the full cost for Medicare beneficiaries. The Medicare amounts listed in Part III Section B. on lines 5, 6, and 7 do not represent all of the organization's revenues and costs associated with its participation in Medicare programs. The methodology used in reporting in Part III Section B Medicare is inconsistent with the other sections in Schedule H, as the instructions limit Medicare revenues and allowable cost to those from only the Medicare Cost Report. Revenue and costs from Medicare Part C patients, Part B physician services billed by the organization, and clinical laboratory services weren't included. In addition, hospitals incur other costs to provide care that Medicare does not allow in the cost report, such as Physician Call pay to ensure adequate physician coverage for the ED.The total revenues and costs attributable to all Medicare services are $137,332,000 and $184,125,000 respectively. This results in a total Medicare shortfall of $46,793,000.Costing Methodology (Part III, Line 8).Medicare allowable costs were calculated using the costing methodologies in the Medicare Cost Report. The cost report arrives at total allowable hospital cost through a cost finding process that includes direct cost allocations and a step-down allocation of indirect or overhead costs. Inpatient operating costs are composed of general inpatient routine and ICU unit costs derived from cost per diems, as well as inpatient ancillary service costs that utilize cost to charge ratios to arrive at cost. Apportionment of cost applicable to hospital outpatient services is through the application of cost to charge ratios. This excludes other costs incurred to provide services of the hospital to the community that the cost report deems as unallowable costs, such as Physician on-call pay. Part III, Line 9b - Provisions On Collection Practices For Qualified Patients Legacy provides care without charge or at amounts less than its established rates to patients who meet certain criteria under its financial assistance policy. Since Legacy does not pursue collection of amounts determined to qualify as charity care, they are excluded from net patient service revenues. Part VI - Needs Assessment The described CHNA provides the primary source for assessing needs. Senior leadership, in conjunction with the Board of Directors, Community Benefit and Commmunity Relations staff continually assesse the needs of the communities it serves through a compilation of primary and secondary market research (qualitative and quantitative), medical staff input, reviewing national trends and practices, working with local foundations and funders regarding their assessments, and working with local community-based partners to understand their needs. The goal is to understand the needs and develop programs specific to the community. Involvement is both proactive and responsive - a leadership role in initiating programs as well as being readily available as a collaborative partner when the community asks. The outcome of these assessments is the development of both long-term and fiscal year plans that are supported by a yearly budget that is proposed by staff and approved by the Board of Directors. These are then aligned to the community health needs identified in the formal CHNA. The region served by LEHHC, along with most of Oregon, is experiencing significant challenges in population growth, economic development, education and health care. Recognizing that social and economic determinants impact health, LEHHC has been and will remain committed to addressing these issues to improve the health of all residents in the community, including equity among ethnically diverse populations. Part VI - Patient Education of Eligibility for Assistance LEHHC employs financial counselors and social workers that assist patients in obtaining coverage for their healthcare needs. This includes assistance with workers compensation, motor vehicle accident policies, COBRA, veterans' assistance, LEHHC's financial assistance program, and public assistance programs, such as Medicaid. The criteria for financial assistance under LEHHC's program is determined based on eligibility for insurance coverage, household income, qualified assets, catastrophic medical events, or other information supporting a patient's inability to pay for services provided. Specifically, the LEHHC Financial Assistance Program provides an uninsured discount of 35% to patients who have resided within LEHHC'S primary service area for a period of six months, are uninsured for hospital care, and have a household income of less than $100,000 annually. Further discounts are available for patients, on a sliding scale, whose household income is less than 400% of the federal poverty level or roughly $97,000 for a family of four in the Portland, Oregon metropolitan area. For patients whose household income is at or below 200% of the federal poverty level, a full subsidy is available. In addition to the household income criteria, the patients' qualified assets (e.g. 25% of household assets), and other catastrophic or economic circumstances are considered in determining eligibility. In addition to financial counselors and social workers, LEHHC makes every effort to communicate its Financial Assistance Program to all patients. This includes signage in main admitting areas of the hospital and brochures explaining financial assistance in all patient care areas, as well as in appropriate languages. Financial counselors are available to assist patients in understanding and applying for available resources, including the LEHHC Financial Assistance Program. LEHHC's website also has information about the availability of financial assistance. LEHHC offers financial assistance customer service Monday through Friday, as well as the availability of voice mail so patients can leave confidential, detailed messages during non-business hours. Finally all of LEHHC's billing statements include information regarding the availability of financial assistance. If LEHHC requires the use of a collection agency, those agencies are required to provide a telephone number that patients can call to request financial assistance.In 2010, Legacy Health established the Health Literacy initiative. Nearly all Legacy employees are touch points to patients and families and health literacy is involved in every touch point. What is health literacy? The Institute of Medicine defines health literacy as the capacity to obtain, understand, and process basic health information and services needed to make appropriate health decisions. In short, health literacy is the ability to understand and act on health information. Nearly half of the U.S. adult population has a low level of health literacy. Patients with low health literacy are less likely to comply with treatment, less likely to seek preventive care and twice as likely to be hospitalized. Quality, safety and cost are all affected by a patients inability to understand medical instructions and to explain their symptoms/issues. Legacy's employees are learning and practicing new way of communicating with patients using health literacy tools such as universal precautions, plain language and teach back methods.Annual education is provided to all billing and admitting staff so they can be kept informed of and speak with knowledge about current financial assistance policies and options. LEHHC provides copies of the latest policies in main admitting areas, as well as through newsletters and other publications. Since 2008, the four county metro area health delivery systems (encompassing all hospitals in the area) and safety net clinics have partnered to establish a seamless, coordinated program to provide care for the low income uninsured, Project Access. This program enables low income uninsured patients to receive continuity of care in earlier stages of acuity due to the collaboration among 2,800 providers and all health systems. Part VI - Community Information LEHHC is located across the Willamette River slightly north of downtown and is in one of the oldest urban neighborhoods in Portland. The primary service area extends from the Columbia River in the north to south of Highway 99E and from Walker Road and St. Helens in the west to NE/SE 161st in the east. The inner primary service area includes the close-in community neighborhoods of Boise, Eliot, Kenton, Piedmont, St. Johns, Irvington, Alameda, Lloyd District/ Sullivan's Gulch, Rose City and Laurelhurst. Zip codes for the five mile area include: 97005-97008, 97201-97222, 97225, 97227, 97229, 97230, 97232, 97233, 97236, 97239 and 97266. The most recently available demographic data is from 2016 to 2021. When available, data at the primary service area level is used, followed by the county (Multnomah) and then the state (Oregon). County data is used most frequently because there is a lack of available data at the zip code level, particularly related to race and ethnicity.The population of the primary service area for Legacy Emanuel was 940,000 approximately with a 5.4% growth projected by 2019. In 2015 the LEHHC primary service area was 71% non-Hispanic white, 11.2% Hispanic, 5.0% African American, 7.3% Asian and Pacific Islander, and 0.6% Native American. The foreign-born population represents 14.2% of total population in the area, an increase of nearly 20 percent since 2005.The African American/Black population continues to be most concentrated in the historical neighborhoods of North/Northeast Portland, but increased housing prices have resulted in the community moving increasingly to East Multnomah County. Multnomah County continues to have three to six times the percentage population of African Americans as the other three counties. Hispanics are moving into the service area at a higher rate than any other group. The Portland Native American community is the ninth largest urban Native American population in the US. With high child poverty and unemployment rates, the Native American community struggles across multiple indicators in contrast to the non-Hispanic white community. The immigrant and refugee population is increasing significantly. Recent immigrants and refugees are more likely to be culturally and linguistically isolated. A small but increasing African refugee population has settled primarily in North and NE Portland and is distinct from the African American/Black population. Available data suggests that the African population is generally poorer than other communities.Census numbers do not adequately represent the true and changing picture of the population. More than 100 languages are spoken in the Portland public schools. Schools near LEHHC are 40% - 70% children of color made up primarily of African-American and increasingly Hispanic students. Schools are experiencing a 50% English-as-a-Second-Language rate and a 50-80% reduced-cost or free lunch rates.Multnomah Countys median household income (MHI) average for the years 2008-2012 was $51,582 with 17.1 percent of the population living below poverty. However, there is a much greater disparity of MHI between communities of color earning half the incomes of non-Hispanic whites in Multnomah County. In Multnomah County, while non-Hispanic white MHI was at $55,346, African Americans had the lowest MHI at $27,347 followed by American Indian/Alaska Native at $29,695 and, Hispanic/Latinos at $36,572. In contrast, Asians MHI was $54,561. Families living below poverty level show non-Hispanic white at 7.9 percent relative to Asians at 12.6 percent, two or more races at 19.6 percent, Black/African American at 32.6 percent, Hispanic/Latino at 30.7 percent and American Indian/Alaska Native at 35.5 percent. The 2011 overall high school graduation rate in Multnomah County was 67.2 percent. Two of three school districts show the non-Hispanic white cohort to have a graduate rate more than fifty percent greater than Native Americans. Portland School District, the largest school district, shows a 15 percentage point difference between the non-Hispanic white student population and African American and Hispanics. The Dignity Health and Truven Health Community Needs Index (CNI) is accepted as the national standard in identifying communities with health disparities and comparing relative need. A higher score indicated a greater need. The locations of two of the top four self-pay zip codes for all Legacy hospitals are in close proximity of LEHHC in St. Johns (97203 and 97217), Boise Eliot (97227) and Cully (97218).The LEHHC five mile primary service area includes four other tertiary hospitals. LEHHC operates a Level I trauma center and Randall Children's Hospital at Legacy Emanuel Medical Center. OHSU located on the southwest side of town operates a Level 1 trauma center, a children's hospital and has the only medical school in Portland. Providence Health operates one hospital about five miles west of LEHHC and the other three miles southeast. Kaiser Permanente formerly operated a hospital about a mile north of LEHHC; but continues to maintain a strong clinic presence in the area.LEHHCs primary service area includes two Medically Underserved Areas (MUA): St. Johns community and SE Portland. With the long-standing income disparities in the LEHHC area, safety net services have expanded in the last decade. Multnomah County Health Department operates FQHCs in Northeast and Southeast Portland. Two blocks from Emanuel is the site of a NARA (Native American Rehabilitation Association) FQHC. Eight years ago a nonprofit volunteer based safety net clinic opened one mile from the hospital which is dedicated to providing primary care for uninsured and Medicaid low income residents, primarily African American, from the immediately surrounding zip codes. Legacy Emanuels internal medicine residency program operates a teaching clinic and a midwifery clinic serving the low income and often uninsured.A local non-profit, Project Access NOW, links uninsured low income individuals to no-cost healthcare services. All of the health systems in the metro area are very involved with this program. Legacy Health provides cash donations, free administrative office space for Project Access NOW as well as clinical services. The Affordable Care Act is significantly increasing the insured rate in Oregon. With a June 2013 Oregon uninsured rate of 14 percent, by June 2014 the rate had decreased to 5.1 percenta 63 percent decrease (from 550,000 to 202,000 people). Most of the newly enrolled are now in theOregon Health Plan which increased 360,000 people--59 percent.In FY 2016, LEHHC provided about $15 million in charity care which accounts for 9% of total unreimbursed costs of $165 million.Legacy Emanuels charity care policy includes patients with incomes up to 400 percent of Federal Poverty Level (FPL). With the advent of the Affordable Care Act, a significant number of people under 139% of the FPL now have Medicaid coverage. This will reduce the self-pay/charity care costs to hospitals; at the same time it is expected to increase the unreimbursed costs of Medicaid. According to the OHA report, all hospitals incurred about 630 million in unreimbursed costs for Medicaid services statewide. Hospitals showed growth in unreimbursed costs due to the expansion of Medicaid as a provision of the Affordable Care Act in 2014. This growth is offset by reductions in charity care costs. Part VI - Explanation Of How Organization Furthers Its Exempt Purpose LEHHC collaborates with other health care providers, community-based organizations, business and the public on projects to improve the health of the community. Examples of clinically based partnerships include, among others: CARES NW (Child Abuse Response and Evaluation Services) is one example of clinically based partnership in collaboration with three health systems. LEHHC serves as the employer and donates the infrastructure for CARES NW. A newer collaborative, Unity Center for Behavioral Health, includes all major health care systems in the metro area and will provide pcychiatric emergency services when it opens in January 2017. Legacy Health has collaborated with more than a dozen community mental health partners in developing this new program.Over 20 years ago, LEHHC recognized that nonprofit organizations spend valuable dollars on office space and infrastructure dollars better spent on meeting their missions. Since then LEHHC has provided free office space and other infrastructure services to three nonprofit organizations on its campus totaling over $90,000 a year in-kind. One organization, the African-American Health Coalition, is dedicated to closing the health inequities gap. In addition to space, Legacy donated a $1.6 million building to the coalition. Other organizations include Oregon Lutheran Synod and Northwest Parish Nurse Ministries. The Ronald McDonald House is located on donated land on the hospital campus. Non-cash donations of resources include clinical and non-clinical services and items, e.g., screenings and support services, internships, information and referral services and health fairs. Legacys warehouse is open to nonprofit organizations to obtain surplus equipment and furniture. In addition, conference room space is made available to local nonprofits for Board and community meetings.As a hospital located in a high density, inner city neighborhood, LEHHC's security department patrols the neighborhoods as a service to those communities. Emanuel employees, local businesses and neighborhood associations collaborated to revitalize a neighboring park which was previously used for drug and other illegal activities. Since that time police incidents have decreased 93 percent.LEHHC clinical staff is involved with local communities through many child safety programs. In 1986, nurses in Emanuel Hospitals Level I Trauma Center developed the Trauma Nurses Talk Tough (TNTT) program. Taught by trauma and emergency medical professionals, the program reaches 56,000 people each year. The American Hospital Association awarded the TNTT program its NOVA Award. In addition, Legacy staff members conduct free education to show parents how to properly install car seats. Last year, Legacy staff fit and sold more than 8,000 bicycle helmets to children at a nominal or no fee based on need. Legacy staff members also provide new parents with training to reduce the incidences of shaken baby syndrome and a Safety Store sells child protection devices for the home at nominal charge.As a tertiary center, LEHHC provides several unique services to a four state region (Alaska, Washington, Oregon and Idaho) such as its Level I trauma center, Randall Childrens Hospital, burn center, and high-risk obstetric services, including a Level III NICU. In addition, LEHHC provides training for interns and residents through its nationally accredited graduate medical education program and partners with schools to provide training and education for nursing and other health professionals. Part VI - Affilated Health Care System Roles and Promotion LEHHC is a subsidiary of Legacy Health (Legacy). Legacy is an integrated health system based in Portland, Oregon and primarily operates five acute care hospitals and related services (e.g., physician practices, hospice, preferred provider network) in the four county metro area of Portland and SW Washington. The Legacy Board is comprised of community and business leaders as well as representatives of the medical staff. The LEHHC medical staff is open, with physicians submitting credentialing information reviewed according to LEHHC policies and standards. While there is investment in a variety of community-based activities and programs as a part of its non-profit status, an overwhelming majority of Legacy and LEHHC's community benefit comes in the form of providing uncompensated care. Legacy's policy of providing care regardless of the ability to pay makes it one of the region's largest providers of uncompensated care in the four-county metropolitan area.In 1998, the Legacy Health Board approved a $10 million Community Health Fund from operating revenue to address major community health issues. About $500,000 annually has been granted to community-based projects addressing racial and ethnic inequities and root causes. These dollars are in addition to Legacys other generous charitable contributions. The Community Health Fund has provided 48 grants since 1998 totaling over $8.1 million, including 18 focused in the LEHHC service area. A recent project was the three-year, $470,000 partnership among three local organizations to reduce childhood obesity among children of color, particularly African American. In 2010, Legacy Health established the Health Literacy initiative. The ability of patients to both understand and act upon the medical information provided to them is critical to their health outcomes. Patients must use information to navigate the health system (complete insurance and government forms, sign consents, schedule appointments), manage diseases and acquire preventive screenings. Providers (defined as all staff interacting with or developing materials used by patients) are responsible for ensuring that patients can act on the information provided. Funded by the Community Health Fund in 2012, Legacy hosted the first Oregon and SW Washington Health Literacy Conference. 360 people from 69 organizations attended. Since 2012, the Health Literacy Conference has been organized every year with more than 500 health professionals attending each year from 80 organizations. Legacy Health is now the recognized leader in moving health literacy forward both in the health delivery system and broader community.Recognizing that education, employment and income inequities exist for communities of diversity, and that health professions are lacking in diversity, Legacy established the Youth Employment in Summer program in 1999. Annually, 13-15 African American, Hispanic and Native American youth receive paid summer employment in departments where they work with health professionals and earn college scholarships between $3,000 and $6,000 annually. Students must remain in school and pursued health careers in order to continue in the program. Some students remain in the program as long as seven years and graduated with degrees in a variety of healthcare fields. The vast majority of the students are the first in the families to go to college. In addition to the Community Health Fund, Legacy provided cash donations to local health and human service, education, economic development and civic organizations. A few examples include Children's Cancer Association, March of Dimes, NW Parish Nurse Ministries, and Self Enhancement Inc. Donations focus on organizations with year-round relationships through programs and board representationspecifically focused organizations addressing disparities. A few examples include Native American Youth and Family Center, Childrens Community Clinic and Outside In. In addition, Legacy Health lab services provided more than $18,000 in in-kind services to the local safety net clinic located 10 blocks from Emanuel and dedicated to serving residents of the inner neighborhoods. Part VI - States Where Community Benefit Report Filed OR true MEDICAL TEAMS INTERNATIONAL 14150 SW MILTON CT TIGARD OR 97224 930878944 501(c)(3) 0 12586 COST EQUIPMENT & SUPPLIES FOR DISASTER ASSISTANCE 1 0 PATIENT NEEDS FOR SAFE DISCHARGE 88530 TRANSPORTATION BURN/WOUND GARMENTS 120 27500 COMPRESSION GARMENTS Grantmaker's Description of How Grants are Used Legacy reviews all organizations prior to donating cash or supplies to ensure their 501(c)(3) status. Legacy regularly donates supplies to Medical Teams International for disaster relief. Several Legacy medical staff members, volunteer for Medical Teams International. X true true false true false true true true true false true true BRIAN P YOUNG MD VP 333157 60193 30908 27414 26422 478094 BRONWYN J HOUSTON PRESIDENT/CAO 166963 13608 -1825 17677 24930 221353 CAROL A BRADLEY SR VP 367266 59973 19241 39410 28016 513906 DONALD A TOUSSAINT VP 199995 34024 39609 34285 13094 321007 19567 DUNCAN R NEILSON MD VP 395187 72610 18614 18830 37027 542268 EVERETT W NEWCOMB III MD SR VP 647865 134905 55321 184869 32075 1055035 45582 GEORGE J BROWN MD President & CEO 1068412 252963 489558 420977 46958 2278868 465036 JOHN J KENAGY SR VP 400720 72160 1221 110568 29763 614432 JOHN P IGUIDBASHIAN MD CARDIO SURGEON 816330 30000 113005 38125 27563 1025023 JONATHAN HILL MD BOARD DIRECTOR 369224 10980 11500 10880 11179 402263 11500 KEYVAN ABTIN MD NEUROSURGEON 700739 69298 5988 16998 27856 820879 LEWIS L LOW MD SR VP 492826 86459 28312 56249 29417 693263 LINDA S HOFF CFO & TREASURER 549960 112672 -2952 147327 31820 838827 LORI J MORGAN MD PRESIDENT/CAO 468073 68734 -1968 46342 30588 611769 MADLYN A MURREY PRESIDENT/CAO 213818 71712 6926 18974 9390 320820 MAUREEN A BRADLEY SR VP 257484 83376 746 26547 23471 391624 MELINDA J MULLER MD VP 343388 59814 -1656 38085 30290 469921 MOLLY F BURCHELL MD VP 367254 51442 2774 37236 22702 481408 MONICA C WEHBY MD PED NEUROSURGEON 710858 38641 -820 26311 12783 787773 P ASHLEY WACKYM MD VP LEGACY RESEARCH 361993 79521 31512 30703 31560 535289 RAMNIK S JHOOTY MD CARDIOLOGIST 482890 219647 -3202 19089 20031 738455 ROBERT E DEWITT Secretary 372971 62942 7682 27402 13386 484383 SANDRA M WANEK MD ECMO SURGEON 481624 470680 853 19251 2873 975281 SONJA O STEVES SR VP 347887 62219 -1421 67984 21620 498289 TRENT S GREEN SR VP 430357 77391 -2318 129568 24527 659525 Part I, Line 1a: Relevant information in regards to selections on 1a. Legacy does periodically reimburse for some travel of companions. During 2015, some travel expenses for companions of Legacy Board Directors and executives were reimbursed. These transactions follow Legacys reimbursement policy requiring documentation and approval of the expenses, prior to reimbursement. These payments are taxable to the individuals and are reported on a W-2 for employees or a 1099 for Board Directors. Part I, Line 5b: Explanation of organization compensation based on revenues of related organization Physicians employed by Legacy affiliates are paid a bonus contingent upon their revenue generated during the year measured by industry standard relative value units (RVU). Part I, Line 6b: Explanation of organization compensation contingent on net earnings from related or Legacy has an at-risk incentive compensation plan for management. The plan is based on meeting goals related to employee engagement, work processes, customer service, clinical quality, financial management, and certain key strategic tactics. In order to payout any at-risk incentive compensation, Legacy must exceed operating margin targets. Part I, Line 8: Amounts reported on 990 VII pursuant to initial contract exemption described in Regs Legacy enters into initial employment agreements with executives that qualify under the initial contract exception. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for key executive positions. The Committee relies on comparable market data and all decisions are documented. Part III, Additional Information Sch J, Part 1, Question 3 Regarding Compensation PracticesDirectors for Legacy started receiving compensation for their services in August 2014. The compensation for 2014 was not paid out until February 2015 and is reported in FY2016 to match the 1099 reporting. They also receive expense reimbursements related to their duties. Any expense reimbursements to board members are reviewed by the Director of Tax for determining 1099 tax reporting. In addition to the Board of Directors compensation, during 2015, Dr. Hill received compensation related to his duties as Medical Director as well as for the Medical Staff at Legacy Emanuel Hospital. Dr. Fullman received compensation for medical services provided to Legacy Meridian Park Hospital. There was no other reportable compensation received by any board member during 2015.Executive compensation for Legacy is designed to recruit, retain and motivate qualified senior management personnel. The comprehensive compensation plan is designed for positions that have a significant impact on the high-level strategic and policy direction of Legacy and its affiliates.Base pay and total compensation (including incentive compensation) for similar positions is established at a level comparable to market compensation for healthcare organizations. External consultants are regularly used to review published compensation surveys of comparable organizations and comparable benchmark positions in the market. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for executive positions. The Committee oversees the system's governance procedures with respect to intermediate sanctions legislation and the evaluation of reasonableness of compensation. The Committee reports to the Board in sufficient detail to enable the entire Board to take such actions as are required to obtain the rebuttable presumption of reasonableness. The Compensation Committee also reviews tax-reporting disclosures.Sch J, Part II, Column Breakdown Of W-2 Or Misc-1099:Column B(i) - Base compensation consists of regular base pay including employee elected deferrals for retirement plans (403(b) and 457(b) plans).Column B(ii) - The incentive compensation program for Legacy is based on predetermined criteria and reviewed and approved by the Board. Bonuses are paid to key employees for interim duties outside their primary responsibilities (e.g. Acting in Capacity).Column B(iii) - Other compensation consists of deferred compensation amounts paid to executives during the current year and were reported on prior form 990 returns. These amounts include arrangements that contain elements of a substantial risk of forfeiture conditioned on continued employment, vesting and/or a noncompete provision upon termination of employment. Distributions from 457(b) plans, reported to the employee on a 1099-R, are also included as other compensation. In addition, imputed income for insurance, cell phone and other benefits is included in other compensation as well as any severance related payments. Column C - Deferred compensation includes the value of defined benefit plans, contributions to defined contribution plans, amounts deferred under the 457(f) plan including earnings, earnings in the 457(b) plan, and the value of the pension restoration plan. Earnings on the 457(f) and 457(b) include gains and losses on the underlying investments. The defined contribution plan is available to all employees as they become qualified to participate. The pension restoration plan provides executive pension benefits in excess of IRS mandated limits on eligible compensation to key executives. The benefits are unfunded and subject to forfeiture. Executive pension benefits are intended to make the executive's retirement benefit, as a proportion of their final average salary, comparable to all other employees, and are treated as income when paid.The Legacy Health Board approved the goals and long-term objectives for the Executive Long Term Incentive Plan effective April 1, 2014 for 3 years ending on March 31, 2017. The plan is discretionary and can be terminated at any time. The purpose of the Plan is to attract and retain highly qualified senior executives, to focus management performance and reward participants for contributing to the accomplishments of Legacys long-term objectives. The long-term strategic goals include the development of a health plan partnership strategy; partner with other local healthcare providers to open a center for behavioral health; expanded use of information technology and data analytics to improve patient care; and executing an urgent care strategy to improve access to care and reduce emergency visits. Targets for operating margins and clinical quality are required over the three year period and all goals are measured at March 31, 2017. Payout is after approval from the Legacy Health Compensation committee and the Legacy Health Board. Column D - Nontaxable benefits include company paid health and welfare and long term care and disability benefits under group plans.Column F - Current year compensation reported as deferred in prior years. KEYVAN ABTIN MD MALPRACTICE COVERAGE X 42862 31498 false true true 31498 Form 990, Part VI, Line 3: Description of Delegated Duties to Management Company Legacy Health (Legacy) provides management services for all of its affiliated companies which includes, accounting, purchasing, contracting, legal, human resources, information technology, billing, facilities, budgeting, transcription, security, public relations, strategic planning, organization development.Cascade Pathology Services provides a Medical Director and pathologists who oversee the pathology laboratory services at LEMHHC. The amount paid for the year ended March 31, 2016 was $755,040. Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder Legacy Health is the sole member of Legacy Emanuel Hospital & Health Center. Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body The Board of Directors includes the following members: (a) The Bishop of the Oregon Synod of the Evangelical Lutheran Church inAmerica (the "Oregon Synod") or the Bishop's designee, who shall serve ex officio;(b) The Bishop of the Episcopal Diocese of Oregon (the "Episcopal Diocese")or the Bishop's designee, who shall serve ex officio;(c) One (1) person appointed by election of the Oregon Synod Council;(d) One (1) person appointed by election of the Convention of the EpiscopalDiocese. Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders The appointed persons by the Oregon Synod Council and the Convention of the Episcopal Diocese may not be removed from the Board without written consent of their respective organizations. Form 990, Part VI, Line 11b: Form 990 Review Process The Legacy Board received a copy of the 990 return prior to filing. At the direction of the entire Board, the Board Compensation Committee reviewed the compensation disclosures and the Board Audit Committee reviewed the 990 return with Management prior to filing. Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts The following is a summary of Legacy's policy and procedures for conflict of interest disclosure, monitoring and resolution.All Legacy employees and non-employees in leadership positions (e.g., Board members, Foundation Trustees, Medical Directors) are required to disclose potential conflicts of interest as the conflict arises. All employees are required to disclose any conflict of interest per the Standard of Conduct policy. Certain groups have annual formal disclosure requirements. Executives and non-employees in leadership positions complete the Conflict Disclosure Statement from the Standards of Conduct policy annually. Officers, Directors, Trustees, Key and Highly Compensated employees are also required to complete a questionnaire covering business relationships, business transactions with interested parties, loans and grants. Conflict Disclosure Statements and questionnaires are returned to Legacy Corporate Compliance or Tax Department for review of the disclosure. If a conflict is disclosed, or identified through any other means, Legacy Corporate Compliance ensures that management mitigates the risk (e.g., discontinues relationship with vendor, segregates responsibilities, recuses Board member from voting in area of conflict) and that the conflict and mitigation steps are reported to the appropriate level (e.g., Compliance Committee, Audit Committee of the Board). Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees The following describes the compensation practices of Legacy and its affiliates.Executive compensation for Legacy is designed to recruit, retain and motivate qualified senior management personnel. The comprehensive compensation plan is designed for positions that have a significant impact on the high-level strategic and policy direction of Legacy and its affiliates.Base pay and total compensation (including incentive compensation) for similar positions is established at a level comparable to market compensation for healthcare organizations. External consultants are regularly used to review published compensation surveys of comparable organizations and comparable benchmark positions in the market. The Compensation Committee of the Board of Directors, none of whom is a Legacy employee, reviews the compensation for key executive positions. The Committee oversees the system's governance procedures with respect to the evaluation of reasonableness of compensation. The Committee reports to the Board in sufficient detail to enable the entire Board to take such actions as are required to obtain the rebuttable presumption of reasonableness. The Compensation Committee also reviews tax-reporting disclosures. Form 990, Part VI, Line 19: Other Organization Documents Publicly Available Legacy Health's audited and interim consolidated financial statements are publicly available on the Electronic Municipal Market Access(EMMA) (www.emma.msrb.org) and DAC Bond (www.dacbond.com) websites. Legacy's audited consolidated financial statements include consolidating schedules which highlights LEHHC's financial results.When changes are made to the LEHHC Articles or Bylaws, LEHHC discloses and attaches copies to the IRS Form 990, which are publicly available by request or on various public websites such as Guidestar(www.guidestar.org). Other governing documents are not available to the public. Other Changes In Net Assets Or Fund Balances - Other Decreases ADDITIONAL MINIMUM PENSION LIABILITY = -$18617294 Other Changes In Net Assets Or Fund Balances - Other Increases CAPITAL CONTRIBUTION FROM RESEARCH = $109131 Other Changes In Net Assets Or Fund Balances - Other Increases ROUNDING = $1 Form 990, Part IV, question 12 Legacy has an audit of its consolidated financial statement which includes consolidating schedules highlighting LEHHC's financial results. Form 990, Part VI, question 2 Legacy Health System CPC, LLC (CPC) is a common pay agent for Legacy and its affiliates. The CPC files all required federal employment tax returns for Legacy and its affiliates. The number of employees reported on Form W-3 for LEHHC, the lab & clinics is 5,315. Form 990, Part X LEHHC participates in the Legacy investment pooled funds which include professionally managed equity and fixed income securities in both separately managed portfolios and commingled investment accounts. Investment returns are prorated according to each affiliate's share of the pool. Form 990, Schedule J Schedule J Reporting of Officers and Senior Management on Legacy Affilate Returns. The Legacy Officers, Senior Vice Presidents and other key employees may have responsibilities for the operations of the entire health system, including the affiliated entities. Their compensation is paid from and reported on the Legacy return(EIN 23-7426300). The compensation is reported again for informational purposes on related affiliated entity returns including, Legacy Emanuel Hospital & Health Center, Legacy Good Samaritan Hospital and Medical Center, Legacy Meridian Park Hospital, Legacy Mount Hood Medical Center, Legacy Salmon Creek Hospital, Legacy Visiting Nurse Association, and Legacy Adventist Venture. LEGACY CLINICS LLC 1919 NW LOVEJOY ST PORTLAND OR 97209 931272735 HEALTHCARE OR -46392752 115854384 LEGACY EMANUEL HOSPITAL & HEALTH CENTER LEGACY LABORATORY SERVICES LLC 1919 NW LOVEJOY ST PORTLAND OR 97209 263597257 HEALTHCARE OR 7579852 43040612 LEGACY EMANUEL HOSPITAL & HEALTH CENTER LEGACY HEALTH 1919 NW LOVEJOY ST PORTLAND OR 97209 237426300 HEALTHCARE OR 501(C)(3) 11b N/A false LEGACY GOOD SAMARITAN HOSPITAL & MEDICAL 1015 NW 22ND AVE PORTLAND OR 97210 930386793 HOSPITAL OR 501(C)(3) 3 N/A false LEGACY MERIDIAN PARK HOSPITAL 19300 SW 65TH AVE TUALATIN OR 97062 930618975 HOSPITAL OR 501(C)(3) 3 N/A false LEGACY MOUNT HOOD MEDICAL CENTER 24800 SE STARK ST GRESHAM OR 97030 930591528 HOSPITAL OR 501(C)(3) 3 N/A false LEGACY SALMON CREEK HOSPITAL 2211 NE 139TH ST VANCOUVER WA 98686 331065485 HOSPITAL WA 501(C)(3) 3 N/A false LEGACY VISITING NURSE ASSOCIATION 815 NE DAVIS ST PORTLAND OR 97210 930848530 HOSPICE OR 501(C)(3) 9 N/A false EMANUEL MEDICAL CENTER FOUNDATION PO BOX 4484 PORTLAND OR 97208 936095667 CHARITABLE FOUNDATION OR 501(C)(3) 7 N/A true RANDALL CHILDRENS HOSPITAL FOUNDATION PO BOX 4484 PORTLAND OR 97208 931314469 CHARITABLE FOUNDATION OR 501(C)(3) 7 N/A true GOOD SAMARITAN FOUNDATION PO BOX 4484 PORTLAND OR 97208 237017276 CHARITABLE FOUNDATION OR 501(C)(3) 7 N/A false MERIDIAN PARK MEDICAL FOUNDATION PO BOX 4484 PORTLAND OR 97208 930773410 CHARITABLE FOUNDATION OR 501(C)(3) 7 N/A false MT HOOD MEDICAL CENTER FOUNDATION PO BOX 4484 PORTLAND OR 97208 930794951 CHARITABLE FOUNDATION OR 501(C)(3) 7 N/A false SALMON CREEK HOSPITAL FOUNDATION PO BOX 4484 PORTLAND OR 97208 830433165 CHARITABLE FOUNDATION WA 501(C)(3) 7 N/A false LEGACY ADVENTIST VENTURE 1919 NW LOVEJOY ST PORTLAND OR 97209 931121816 HEALTHCARE OR 501(C)(3) 9 N/A false LEGACY HEALTH FOUNDATION 1919 NW LOVEJOY ST PORTLAND OR 97209 465562403 CHARITABLE FOUNDATION OR 501(C)(3) 7 N/A false LIFE FLIGHT NETWORK LLC 22285 YELLOW GATE LANE SUITE 102 AURORA OR 97002 205016802 EMER AIR AM OR N/A Related 5111792 4342089 false false 0.32000 false true true true true false true true true true true false true false true true true true true EMANUEL MEDICAL CENTER FOUNDATION c 1806223 Cash EMANUEL MEDICAL CENTER FOUNDATION i 66780 Cash EMANUEL MEDICAL CENTER FOUNDATION m 227294 Actual Cost RANDALL CHILDRENS HOSPITAL FOUNDATION c 1362022 Cash RANDALL CHILDRENS HOSPITAL FOUNDATION m 301634 Actual Cost